RESET
REG REQUISITION #
__________________ (for hires)
REQUIRED
UNIVERSITY SUPPORT STAFF (USS)
UNCLASSIFIED
PREFERRED NAME
NAME (First, Middle, Last, Suffix)
DEPT ID
EMPLOYEE ID
EFFECTIVE DATE
GENDER
PER 38 (2/14/2016)
KANSAS STATE UNIVERSITY
APPOINTMENT FORM (University Support Staff and Unclassified)
DEPT NAME
*SSN
RCD#
END OF APPT DATE
eID
BIRTHDATE
MARITAL STATUS
EDUCATION
*Employee Notification-Required SSN Disclosure: used for tax withholding, recordkeeping, and government reporting. Solicited per K.S.A. 76-725.
HOME ADDRESS
COUNTRY
ADDRESS 1
ADDRESS 2
CITY
COUNTY
STATE
Ethnic Groups (Mark all that apply)
ZIP CODE
HOME PHONE
MILITARY STATUS
Disabled
Disabled Veteran
HIRE
Yes
No
Hispanic or Latino?
ETHNIC GROUP: American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
ADD CONCURRENT JOB
ACTION
JOB TITLE
FLSA EXEMPT
GRADE (USS)
Yes
WITHHOLD HOME ADDRESS/PHONE IN CAMPUS PHONEBOOK
REASON
NON-EXEMPT
COMP RATE
CORRECT
No
UPDATE
POSITION #
JOB CODE
REG/TEMP
FULL OR PART TIME
FTE
OR 12-month basis
9-month basis
TAX LOCATION
OR Bi-Weekly
Hourly
EMPLOYMENT DATA (Classified)
PROBATION DATE
EMPLOYMENT STATUS
Probationary
Permanent
Trainee
BENEFIT PROGRAM PARTICIPATION
BENEFIT PROGRAM GEN
BENEFIT RCD #
IDENTIFICATION DATA (If not a US Citizen, complete PER-15.)
VISA TYPE
CITIZENSHIP STATUS
EDUCATION DATA
DEGREE
SCHOOL
DATE ACQUIRED
MAJOR
UNCLASSIFIED DATA
TENURE
EFF. DATE
TEACHING FAC
FACULTY SENATE
PREVIOUS EMPLOYMENT If appointee has previously or is currently employed by State or Local Government, or any other State agency
including, KSU, give agency name(s), date(s) of employment and employee ID, if known.
ADDITIONAL INFORMATION
FUNDING INFORMATION Updated by Departments in HRIS. For department use only.
PROJECT #
PROJ ECT DESCRIPTION
FUND SOURCE
ORG
AWARD (If applicable)
FTE
ANNUAL AMT
Non-Exempt Positions: hours applied to health insurance eligibility for the Affordable Care Act will be based on actual hours worked and reported in HRIS
Exempt Positons: hours applied to health insurance eligibility for the Affordable Care Act will be based on the FTE equivalency
EMPLOYEE OATH
(K.S.A. 75-4308) I do solemnly (swear) (affirm) that I will support the Constitution of the United States and the Constitution of the State of Kansas and
faithfully discharge the duties of my office or employment. So help me God.
Employee’s signature ____________________________________________________
SUBSCRIBED AND SWORN TO before me this _____ day of________________20____
Notary Public___________________________________________________________
Spoken English Competency must be completed for all new faculty hires. Please complete and attach a PER 20, Faculty and GTA Spoken
English Competency Assessment Sheet.
_______________________________________________________________________________
EMPLOYEE SIGNATURE
_______________________________________________________________________________
SIGNATURE(S) OF UNIT OR DEPARTMENT HEAD, DEAN AND/OR VICE-PRESIDENT
___________________
DATE
___________________
DATE
State of Kansas
SUBSTANCE ABUSE POLICY
AFFIRMATION FORM
RESET
Statement of Policy
Employees are the State of Kansas' most valuable resource and, therefore, their health and safety is a serious
concern. The State of Kansas will not tolerate substance abuse or use which imperils the health and well-being of its
employees or threatens its service to the public. Furthermore, employees have a right to work in an environment free of
substance abuse and with persons free from the effects of drug or alcohol abuse. It shall therefore be the policy of the
State of Kansas to maintain a workforce free of substance abuse.
A.
Reporting to work or performing work for the state while impaired by or under the influence of controlled
substances or alcohol is prohibited.
B.
The unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in
the workplace, or while the employee is on duty, official state business or stand-by-duty.
C.
Violation of such prohibitions by an employee is considered conduct detrimental to state service and may result
in a referral to the Employee Assistance Program or discipline in accordance with K.S.A. 75-2949d, or other
appropriate administrative regulations.
D.
Employees are required by federal law to notify the employing state agency head in writing of his or her
conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days
after such conviction.
(1)
(2)
An employee who is convicted of violating any criminal drug statute in such workplace situations as
stated above will be subject to discipline in accordance with K.S.A. 75-2949d, or other appropriate
administrative regulations.
A conviction means a finding of guilt (including a plea of nolo contendre) or the imposition of a
sentence by a judge or jury, or both, in any federal or state court.
E.
Agencies that receive federal grants or contracts must, in turn, notify federal granting agencies in writing,
within ten calendar days of receiving notice from an employee or otherwise receiving actual notice of such
conviction. Employers of convicted employees must provide notice, including position title to every grant
officer or other designee on whose grant activity the convicted employee was working, unless the Federal
agency has designated a central point for the receipt of such notices. Notice shall include the identification
number(s) of each affected grant.
F.
Employees will be given a copy of the Substance Abuse Policy. Employees will be informed that they must
abide by the terms of the policy as a condition of employment and of the consequences of any violation of such
policy.
AFFIRMATION OF POLICY
As an employee for the State of Kansas, I affirm that I have read and understand the meaning of the above
Substance Abuse Policy. I am aware of the provisions of this policy which is mandated by the Federal Drug-Free
Workplace Act, and that a violation of this policy will result in disciplinary action as stated above.
Name of Employee:
_____________________________________
Soc. Sec. No.___________________________
367 Kansas State University
Agency Number and Name:_________________________________
Employee ID No. _______________________
__________________________________________
(Signature of Employee)
________________________________
Date
__________________________________________
(Signature of Agency Representative)
________________________________
Date
DPS 417 Original to Agency. Copy to Employee
Rev. 5/2/07
Intellectual Property Agreement
Kansas State University
Preamble
The Intellectual Property Policy adopted in November 1998 by the Kansas Board of
Regents requires that employment contracts or agreements of all Kansas State University
employees, including part-time and student employees, will include a formal notice of and
acceptance of the KBOR and KSU policies on intellectual property. This form serves as that
notice and acceptance. It is completed at the time of initial employment. The original copy will
be retained in the employee’s personnel records.
One purpose of these intellectual property policies is to foster both the development and
the dissemination of useful creations, products or processes. The creation of products and
materials is encouraged by providing a mechanism for rewarding their creators. Dissemination of
products and materials is encouraged by providing for their protection, thus making their
commercial development and public application attractive with the intent of providing the most
benefit for society. A second purpose of these policies is to clarify individual rights and
institutional rights associated with ownership and with the distribution of benefits that may
derive from the creation of various types of intellectual property.
The KSU Intellectual Property Policy may be found online in the University Handbook at
http://www.k-state.edu/provost/universityhb/fhxr.html. The Kansas Board of Regents policy may
be found at
http://www.kansasregents.org/about/policies_by_laws_missions/board_policy_manual_2/
Statement of Agreement:
1. I agree to abide by the stipulations and procedures set forth in the intellectual property
policies of Kansas State University and the Kansas Board of Regents, and I agree to assign and
do hereby assign to the University my right, title, and interest in inventions resulting from my
employment as required by those policies.
2. I will not enter into any agreement creating patent, copyright, or trademark interests or
obligations that is in conflict with KBOR and KSU policies.
________________________________
Signature
_________________________
Department/Unit
_______________________________
Name (Please Print)
_________________________
Date
Form W-4 (2016)
Purpose. Complete Form W-4 so that your employer
can withhold the correct federal income tax from your
pay. Consider completing a new Form W-4 each year
and when your personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2016 expires
February 15, 2017. See Pub. 505, Tax Withholding
and Estimated Tax.
Note: If another person can claim you as a dependent
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,050 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2016. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
G
• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . .
▶
Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.)
H
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2
to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Reset
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
2
Last name
Home address (number and street or rural route)
3
Single
Married
2016
Your social security number
Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
9 Office code (optional)
Kansas State University, 103 Edwards Hall, Manhattan, KS 66506
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Please check one: Appointment
Change Exempt Renewal
10
Employer identification number (EIN)
48
Cat. No. 10220Q
6029925
Form W-4 (2016)
KANSAS
K-4
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
(9/07)
The following instructions will assist you in
completing the worksheet and K-4 form below.
After you have completed the K-4 form,
detach it and give it to your employer. For
assistance with this form, call KDOR (Kansas
Department of Revenue) at 785-368-8222.
Purpose of the K-4 form: A completed
withholding allowance certificate will let your
employer know how much Kansas income tax
should be withheld from your pay on income
you earn from Kansas sources. Because your
tax situation may change, you may want to
refigure your withholding each year.
Exemption from withholding: To qualify for
exempt status you must, 1) Verify with KDOR
that last year you had the right to a refund of
all STATE income tax withheld because you
had no tax liability; 2) Verify with KDOR that
this year you will receive a full refund of all
STATE income tax withheld because you will
have no tax liability.
filed with your employer; otherwise, your
employer must withhold Kansas income tax
from your wages without exemption at the
“Single” allowance rate.
Notes: Your status of “Single” or “Joint” may
differ from your status claimed on your
Federal Form W-4. Claiming more than the
proper amount may result in taxes owed when
filing your state income tax.
Head of household: Generally, you may
claim head of household filing status on your
tax return only if you are unmarried and
pay more than 50% of the cost of keeping
up a home for yourself and for your
dependent(s).
Basic Instructions: If you are not exempt,
complete the Personal Allowances
Worksheet below. The allowances claimed
on this form should not exceed that claimed
under “Exemptions” on your Kansas income
tax return. To avoid owing taxes when you
file, follow the suggested allowance rate
selection on line A below. This form must be
Nonwage income: If you have a large
amount of nonwage Kansas source income,
such as interest or dividends, consider making
estimated tax payment using form K-40ES,
Estimated Tax for Individuals. Otherwise, you
may owe additional tax when filing your state
income tax return.
Personal Allowance Worksheet (Keep for your records)
A Allowance Rate:
If you are a single filer mark “Single”
If you are married and your spouse has income mark “Single”
If you are married and your spouse does not work mark “Joint”
}
Single
Joint
B Enter “0” or “1” if you are married or single and no one else can claim you as a dependent (entering “0” may
help you avoid having too little tax withheld) ..............................................................................................................
B _________
C Enter “0” or “1” if you are married and only have one job, and your spouse does not work (entering “0” may
help you avoid having too little tax withheld) ..............................................................................................................
C _________
D Enter “1” if you will file head of household on your tax return (see conditions under “Head of household” above) ....
D _________
E Enter the number of dependents you will claim on your tax return. Do not claim yourself or your spouse or
dependents that your spouse has already claimed on their form K-4. .......................................................................
E _________
F Enter “1” if you have at least $1,500 of child or dependant care expenses for which you plan to claim a credit and
your household income is below $50,000 ..................................................................................................................
F _________
G Add lines B through F and enter the total here ........................................................................................................
G _________
b
K-4
(9/07)
Cut here and give this K-4 form to your employer. (Keep the top portion for your records.)
Kansas Employee’s Withholding Allowance Certificate
Reset
Whether you are entitled to claim a certain number of allowances or exemptions from withholding is
subject to review by KDOR. Your employer may be required to send a copy of this form to KDOR.
1 Print your first name and middle initial
Last Name
Mailing Address
2 Social Security Number
3 Allowance Rate
Mark the allowance rate selected in line A above.
City or Town, State, and ZIP Code
Single
Joint
4 Total number of allowances you are claiming (from line G above) .............................................................
4
5 Enter any additional amount you want withheld from each paycheck (this is optional) .............................
5
6 I claim exemption from withholding. You must meet the conditions explained in the “Exemption from
withholding” instructions above. If you meet those conditions, write “Exempt” on this line. .....................
6
$
Note: KDOR will receive your federal W-2 forms for all years claimed Exempt.
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief it is true, correct, and complete.
SIGN
HERE
`
7 Employer’s name and address
Kansas State University, 103 Edwards Hall, Manhattan, KS 66506
DATE
8 EIN (Employer Identification Number)
48 6029925
KANSAS STATE UNIVERSITY
AUTHORIZATION FOR DIRECT DEPOSIT OF EMPLOYEE PAYROLL AND/OR
EMPLOYEE TRAVEL AND EXPENSE REIMBURSEMENT
RESET
PER-58
(8/2014)
EMPLOYEE INFORMATION
DEPARTMENT NAME
EMPLOYEE ID
Last four numbers of SSN
NAME (Last, First, MI)
XXX-XXSECTION A: ENROLLMENT OR CHANGE AUTHORIZATION:
You may select up to a maximum of nine accounts within six financial institutions for electronic funds transfer (EFT) for payroll funds and
only one account for the travel and expense. You should complete additional pages of this form, as needed.
SELECT ONE
New Enrollment  Select One
EFT  Complete Section B and C
Skylight Paycard  Complete Section C only
Account Change
SELECT ONE OR BOTH
Payroll
Travel and Expense
EFFECTIVE DATE
SECTION B: Form must be accompanied by a voided check for checking accounts or deposit slip for savings accounts for EACH account.
FINANCIAL INSTITUTION INFORMATION
NAME
BRANCH
CITY
STATE
ZIP
ACCOUNT DISTRIBUTION DATA:
PRIORITY #
TRANSIT #
ACCOUNT #
% NET PAY/AMOUNT
MARK THE APPROPRIATE BOXES BELOW:
Checking
Savings
International ACH Bank – mark this if deposit to this account
may be transferred to a financial agency outside the U.S.
Use this account for my travel and expense reimbursements
FINANCIAL INSTITUTION INFORMATION:
NAME
BRANCH
CITY
STATE
ZIP
ACCOUNT DISTRIBUTION DATA:
PRIORITY #
TRANSIT #
MARK THE APPROPRIATE BOXES BELOW:
Checking
Savings
ACCOUNT #
International ACH Bank – mark this if deposit to this account
may be transferred to a financial agency outside the U.S.
% NET PAY/AMOUNT
Use this account for my travel and expense reimbursements
SECTION C
I understand that if no travel and expense reimbursement account is selected, the priority#1 account will be the account my travel and
expense reimbursement will be deposited into. I authorize the State of Kansas to deposit my employee pay directly to the account(s)
indicated above and to correct any errors which may occur from these transactions. I also authorize the Financial Institution to post
these transactions to these accounts. This authorization is to remain in force until the State of Kansas receives written notice from me to
change this authorization.
EMPLOYEE SIGNATURE
DATE